Provider Demographics
NPI:1336556240
Name:ANDERSON, KEISHA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:KEISHA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 BRUCKNER BLVD APT 2F
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-6539
Mailing Address - Country:US
Mailing Address - Phone:347-125-2287
Mailing Address - Fax:212-371-0532
Practice Address - Street 1:2141 BRUCKNER BLVD APT 2F
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-6539
Practice Address - Country:US
Practice Address - Phone:347-125-2287
Practice Address - Fax:212-371-0532
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2888701164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse